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I
mportance
of
the
use
of
protocols
for
the
management
of
analgesia
and
sedation
in
pediatric
intensive
care
unit
R
ev
A
ssoc
M
ed
B
ras
2016; 62(6):602-609
605
required based on the patient conditions.
4,33
The COM-
FORT-B scale is also validated in Portuguese, with its use
recommended.
34
The daily interruption is being used for a long time in
adult ICUs, demonstrating benefits such as a 2.4-day de-
crease in mechanical ventilation (p=0.004) and a 3.5-day
decrease in length of ICU stay (p=0.02), without increase
in the number of complications.
3
Daily interruption of se-
dation has always been discussed in pediatric ICU because
of technical difficulties when compared to adult practice,
greater risk of adverse events, including accidental trache-
al extubation, and loss of invasive devices. Nevertheless, re-
cent studies showed success in the use of daily interrup-
tion in pediatric ICUs. Gupta et al. demonstrated a decrease
in duration of ventilatory support, leading to a reduction
from 13.01 days in the control group to 8.4 days in the dai-
ly interruption group (p=0.028); shorter length of ICU stay,
from 14 days in the control group to 11 days in the inter-
vention group (p=0.023); lower doses of midazolam used
in the daily interruption group (p=0.002), implicating low-
er hospitalization costs without an increase in the num-
ber of adverse events.
35
Another study, by Verlaat et al.,
showed similar results, with a significant decrease in sed-
ative and analgesic agents used; less time of mechanical
ventilation and decreased length of ICU stay with no in-
crease in the numbers of adverse events.
36
A recent study
by Vet NJ et al.
,
however, did not showmuch benefit in the
use of daily interruption strategies to shorten the duration
of mechanical ventilation or hospitalization, or the quan-
tities of sedatives used, with the use of these strategies po-
tentially associated with a higher 30-day mortality rate,
without explaining the reasons behind this fact.
37,38
The use of daily interruption together with sponta-
neous breathing tests also showed benefits in the reduc-
tion of the need for ventilatory support in 3 days (p=0.002),
ICU length of stay in 3.8 days (p=0.01) and length of hos-
pital stay in 4.3 days (p=0.04).
3
The choice of the ideal sedative agent is difficult, and
must take into account the pharmacology of the drugs
and the different pathologies. New studies have shown
that the use of benzodiazepines leads to a longer need for
ventilatory support (1.9 days, p<0.00001) and longer ICU
length of stay (1.65 days, p=0.0005), as demonstrated by
a review and meta-analysis by Fraser et al.
29,39
Also, it was
shown that the prevalence of delirium, in the use of non-
benzodiazepine agents, is lower, implicating in smaller
hospitalization cost.
29,40
Recently, the preferential use of
non-benzodiazepine sedatives, such as dexmedetomidine
and propofol, has been advocated based on the Pain, Agi-
tation and Delirium (PAD) guidelines for adult patients.
9
Propofol is a safe drug for adult use; however, it is not
yet approved for continuous infusion in children due to
the higher risks of propofol infusion syndrome, which can
be lethal, more common in those patients with concomi-
tant use of cathecolamines and corticosteroids.
41-43
Recent
studies by Koriyama et al. and by Krussell et al. showed
that the use of continuous infusion of propofol limited to
4 mg/kg/h for less than 48 hours is safe, with no cases of
propofol infusion syndrome reported in children.
44,45
Another sedative agent indicated for adult use, with
benefits over benzodiazepines, is dexmedetomidine, an alfa-
2 agonist with sedative and analgesic properties. Riker et al.
demonstrated a decrease in duration of mechanical venti-
lation and a reduction in the prevalence of delirium in adults,
when comparing the use of dexmedetomidine to benzodi-
azepines.
46
MacLaren et al. showed a lower incidence of de-
lirium without more adverse reactions.
47
Ozaki et al. stud-
ied the use of continuous infusion of dexmedetomidine in
pediatric setting, for longer than the recommended time of
48 hours and at doses of 0.7mcg/kg/h. The patients reached
a good level of sedation with the use of the drug for nearly
6 days, with no more adverse events, rebound symptoms or
abstinence.
48
Other studies showed that the use of dexme-
detomidine is safe in patients with congenital heart diseas-
es and in the post-operatory of cardiac surgery without hy-
potension and bradycardia harmful to the patient.
49-53
Management of abstinence syndrome
Prolonged administration of opioids and/or benzodiaz-
epines leads to tolerance. Rapid suspension of these med-
ications implicates a myriad of signs and symptoms, called
abstinence syndrome. However, its diagnosis is compli-
cated in virtue of a superposition of signs of pain, agita-
tion, discomfort, and delirium. These factors must be ex-
cluded to confirm the diagnosis of abstinence, especially
in children that received more than 5 days of sedation/
analgesia. Abstinence syndrome has a prevalence of 34-
70% in patients in use of analgesia/sedation, leading to
problematic consequences, including increased morbid-
ity, length of stay, and psychological alterations.
54,55
To
improve its evaluation, the use of assessment scales, such
as the WAT-1 scale (Assessment Tool Version-1) or the
SOS scale (Sophia Observation withdrawal Symptoms)
4
(A-level recommendation by Harris et al. guideline
4
), is
recommended. The WAT-1 scale is already validated in
pediatrics and translated into Portuguese.
56
There is no consensus regarding the management
scheme of opioid or benzodiazepine weaning in the ab-
stinence syndrome, but many studies have been per-
formed on the recognition of this entity, its monitoring